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INTRODUCTION

Access to health care has two major components. First and most frequently discussed is the ability to pay. Second is the availability of health care personnel and facilities that are close to where people live, accessible by transportation, culturally acceptable, and capable of providing appropriate care in a timely manner and in a compatible language. The first and longest portion of this chapter dwells on financial barriers to care, specifically the access challenges faced by the uninsured and the underinsured. The second portion touches on nonfinancial barriers. The final segment explores the influences other than health care (in particular, socioeconomic status and race/ethnicity) that are important determinants of the health status of a population.

FINANCIAL BARRIERS TO HEALTH CARE

Lack of Insurance

In 2018, Dan Coverless noticed that he was urinating a lot and feeling weak. He lived in South Carolina and earned $9,500 per year working part-time as a construction worker. Because South Carolina did not elect to participate in the Affordable Care Act’s Medicaid expansion, Mr. Coverless was not eligible for Medicaid despite his low income. He also did not qualify for federal tax subsidies to purchase private insurance, which had annual premium costs of more than half his income. His friend told him that his symptoms might mean that he had diabetes and that he should go see a doctor, but lacking health insurance, Mr. Coverless was afraid of the cost. Eight days later, his friend found him in a coma. He was hospitalized for diabetic ketoacidosis.

Health insurance coverage, whether public or private, is a key factor in making health care accessible. Despite gains in insurance coverage since enactment of the Affordable Care Act (ACA) in 2010, 28 million people in the United States in 2017 had no health insurance whatsoever (Fig. 3–1). Forty-six percent of the population was covered by employer-based private insurance, 9% by individual private insurance, 17% by Medicare, and 19% by Medicaid, leaving 9% uninsured (Table 3–1).